Failure to Follow Two-Person Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
A deficiency occurred when a qualified medication aide (QMA) performed a mechanical lift transfer for a resident without the required assistance of a second staff member. The resident, who had diagnoses including anemia, obesity, hyperglycemia, and chronic kidney disease, was ordered to be transferred using a Sara lift with two staff assisting. During the transfer, the QMA completed the process alone and subsequently repositioned the resident in bed by herself, at which point a popping noise was heard and the resident experienced numbness in her left arm. An x-ray later confirmed a left humerus fracture. Interviews and record reviews confirmed that the facility's policy required two staff members for all mechanical lift transfers, including the Sara lift. The QMA involved acknowledged that she was alone during the transfer and repositioning, and stated she had not received training or education on the specific requirements for Sara lift transfers. Other staff and the administrator also confirmed the two-person requirement for such transfers and repositioning, indicating that the policy was not followed during this incident.